TY - JOUR
AU - Arredondo, Elva M.
AB - Abstract Background Community-based interventions are needed to reduce the burden of childhood obesity. Purpose To evaluate the impact of a multi-level promotora-based (Community Health Advisor) intervention to promote healthy eating and physical activity and prevent excess weight gain among Latino children. Methods Thirteen elementary schools were randomized to one of four intervention conditions: individual/family level (Family-only), school/community level (Community-only), combined (Family + Community), or a measurement-only condition. Participants were 808 Latino parents and their children enrolled in kindergarten through 2nd grade. Measures included parent and child body mass index (BMI) and a self-administered parent survey that assessed several parent and child behaviors. Results There were no significant intervention effects on children's BMI z-score. The family intervention changed several obesity-related child behaviors (e.g., fruit/vegetable consumption) and these were mediated by changes in parenting variables (e.g., parent monitoring). Conclusion A promotora-based behavioral intervention was efficacious at changing parental factors and child obesity-related health behaviors. Childhood obesity, Latino, Diet, Physical activity Introduction The prevalence of overweight and obesity among children has been climbing steadily, with 32% of children now overweight and more than 17% obese [1]. Mexican American children aged 6–11 years have the highest levels of obesity (25%) when compared with non-Hispanic Whites (19%) and non-Hispanic Blacks (19%) [1]. Obesity tracks strongly from childhood and adolescence into early adulthood [2] and Latinos have a greater lifetime risk of developing diabetes compared with non-Hispanic Whites and Blacks [3]. Effective childhood obesity prevention programs are needed, especially those targeting disadvantaged subgroups such as Latinos. However, to optimize comprehensiveness and replicability, such programs need to be cast within a conceptual framework that guides the form and sequence of activities. Ecological models of behavior change offer a comprehensive framework to target behavior change at multiple levels [4] and through multiple communication channels [5]. Social-Cognitive Theory [6] and the Health Belief Model [7] provide the framework for targeting specific cognitions and attitudes to support behavior change (Social-Cognitive Theory: self and family control; Health Belief Model: barriers). Models that are culturally relevant are likely to be more effective [8]. Elder et al. [5] developed a version of the socioecological framework for promoting health in Latino communities. Within their framework, proximal (vs. distal) outcomes are primarily behavioral, while proximal influences relevant to child health derive from key individuals in the child's social network, especially family, friends, and teachers. More distal to these influences are organizational and community influences such as school and community physical characteristics (e.g., structure and quality of playgrounds, density, and quality of food outlets). Latino health promotion programs often involve promotoras who serve as health advisors to families or who promote broader organizational and community change [9]. Beginning with behavioral targets, important behavioral risk factors for childhood obesity are low physical activity, high sedentary behavior, and consumption of calorie-dense, nutrient-poor foods. Recent estimates confirm that few children are meeting physical activity guidelines: Only 42% of 6–11 year olds and 7.6% of 16–19 year olds [10]. For cultural, socioeconomic, or environmental reasons, Latino children spend more time watching TV than non-Hispanic White children [11], which is associated with greater calorie consumption [12], higher body mass index (BMI) levels and greater body fat [13]. Intake of energy-dense and nutrient-poor foods [14], including sugar-sweetened beverages [15], is associated with overweight. Among Latinos, a notable contributor to consumption of energy-dense foods is away-from-home eating [16]. Extending to the social environment, parents play a critical role in influencing children's behaviors through parental practices and parenting styles [17, 18]. The home environment is particularly important to physical activity in poor urban settings that lack safe and accessible recreational facilities [19]. Among Latinos, parental control over food, prompting to eat, and feeding styles are associated with children's unhealthy eating patterns and obesity [20]. Thus, parent participation in childhood weight control programs is critical for optimal results [21]. Neighborhood environments are related to obesity through several factors including less access to healthy food outlets and recreational facilities, which put poor and minority communities at special risk [22]. Interventions are needed that simultaneously target obesity-related factors at multiple levels. Unfortunately, few community-based environmental change interventions targeting childhood obesity exist. Studies seeking to prevent and control childhood obesity have obtained mixed results. Some studies have not achieved reductions on child BMI [23–25] while others have demonstrated a reduction in overweight and obesity in children [26–28]. Few of these studies involved a partnership with city-wide businesses and organizations to address the problem. One promising intervention engaged school personnel, family members, and city organizations in intervention activities that included modifying the school curriculum, engaging restaurants to modify their menus, and walk to school programs [29]. Making environmental changes is challenging and complicated, necessitating the involvement of stakeholders, community leaders, and community members [30, 31]. Involving community leaders such as promotoras is a culturally appropriate approach for addressing a variety of health issues that impact underserved communities including Latinos [32]. Promotoras are often from the target communities and have been effective in modifying multiple levels of influence associated with health issues among Latinos [9]. Language and cultural factors are taken into consideration when implementing program activities by promotoras [33]. Factorial designs are optimal for evaluating the independent and combined effects of multi-level interventions attempting to change several health behaviors associated with obesity. Testing these types of approaches is urgently needed given the prevalence of childhood obesity among Latinos and evidence documenting the association between the several health behaviors and childhood obesity among Latinos. Yet, a Cochrane review (2005) showed that studies targeting only physical activity or diet produced somewhat more promising results than have those targeting both [34]. Nevertheless, given the co-occurrence of health behaviors and to maximize the potential for weight loss and minimize weight gain, targeting both sides of the energy balance equation compelled us to conduct this study. The purpose of this study was to compare the independent and combined effects of changes in home/family environments and changes in school/community environments to prevent and control childhood obesity among Latinos. It was hypothesized that children who received the home/family environment and/or the school/community environment interventions would have lower BMI z-scores compared with children who did not (at the end of the 3-year intervention). Secondary hypotheses proposed that the combined intervention (home/family and school/community) would result in healthier eating habits and more physical activity in these children compared with the behaviors of children who did not receive the combined interventions. Moreover, given that the mechanism for behavior change in children's diets and physical activity is through proximal influences such as parenting behaviors, it was hypothesized that parent-related changes would mediate changes in children's weight-related health behaviors. Methods The Aventuras para Niños study (herein referred to as Aventuras) was a 3-year, 2 × 2 factorial design randomized controlled community trial with 13 schools randomized to one of four conditions: Home/Family environmental change (Family-only), Community-only environmental change (Community-only), Family-plus-Community-environmental change (Family + Community), and a no-treatment control condition. The primary study outcome was child BMI z-score while secondary behavioral outcomes were child diet, physical activity, and sedentary behavior. Parenting variables were the targeted mediators of change for the family intervention. Detailed study methods for Aventuras have been previously published [35, 36]. In brief, a total of 808 parent–child dyads with a child enrolled in kindergarten through second grade were recruited from among 13 participating elementary schools to participate in the evaluation cohort. The Institutional Review Board at San Diego State University approved this study, which took place in the South Bay region of San Diego County, adjacent to the US–Mexico border. All schools in the target region were identified and screened for the following eligibility criteria: (1) Latino enrollment of at least 70%; (2) a defined attendance boundary (no charter or magnet schools); and (3) no other obesity prevention programs or additional physical education training for teachers within the past 4 years. Project staff contacted the principal of each school, described the study objectives and methods, determined whether inclusion criteria were met and obtained consent to participate in and be randomized to one of the four conditions. Twenty-five schools were identified; five were deemed ineligible given their current involvement in similar interventions, and seven refused to participate. Parents were recruited directly on school grounds, during school presentations, and through fliers sent home with students. Eligible families self-identified as Latino, had a child in kindergarten, first, or second grade who attended one of the 13 schools, had no major health problems that limited participation, lived within the school attendance boundaries, and intended to live in the area for at least 1 year. In accordance with the study design, schools were the unit of randomization and individual participants were the unit of analysis. Randomization of schools to study conditions took place immediately after all participants completed baseline measures. Table 1 provides an overview of the theoretical approach, as well as the intervention components and fidelity. Table 1 Overview of multilevel intervention components, theoretical approach, and fidelity Components . Theoretical models/constructs . Delivery method/channel . Intended implementation frequency . Actual implementation frequency, mean ± SD, range . Family intervention Promotora home visits Health Belief Model Promotoras discussed with participants ways to overcome barriers to healthy eating and physical activity, ways to prepare healthy meals in the home, benefits of promoting healthy eating and PA in their children (e.g., behavioral benefits), ways to set appropriate goals for the family and monitor healthy eating in the home, and modeling healthy eating. 1 per month for 7 months (over one school year) Home visits Newsletters, recipe cards, goal setting Barriers 18% and 53% of participants received all 6 or all 7 visits, respectively Social Cognitive Theory Group mean = 5.5 ± 2.2 visits, range 0–7 (assessed by promotoras' tracking records) Behavioral Capability, Outcome Expectancies Self-Control, Modeling, and Self-efficacy Booster phone calls Discuss barriers (HBM) and Self-control (SCT) Promotoras called participants 4 calls over 2 years Booster Calls Goal setting, monitor progress 0 = 23%, 1 = 18%, 2 = 19%, 3 = 20%, 4 = 20% Group mean = 1.9 ± 1.5 calls, range 0–4 (assessed by promotoras' tracking records) Community intervention School playgrounds (improvements) and salad bars (implementation and improvement); community parks (improvements) Physical structure (SMHB) Four community Promotoras All playgrounds and salad bars from the six schools (for 3 years) Peaceful Playgrounds® All 6 schools improved their playgroundsa Salad bars at school cafeterias All six schools had salad bars, but none improved their displaya Community parks All community parks were assessed and only one was deemed as needing improvements. This park improveda. Teachers' discipline and classroom practices Social structure and policies (SMHB) Four community Promotoras All classrooms and teachers (3 years) Water bottles in classrooms 34% of classrooms in all six schools had visible water bottles (within school, range = 0%–63%, assessed by direct observation)b TAKE 10! 40% of teachers among all 6 schools reported using TAKE 10! (within school range was 23%–61%, assessed by returned calendars) a Home fun 31% of teachers among all six schools reported using Home Fun (within school range was 4–61%, assessed by returned calendars) a Physical education equipment, children's menus at restaurants Availability of protective/harmful products (SMHB) Four community Promotoras All classrooms and restaurants (3 years) Equipment for play 41% of classrooms in all 6 schools had equipment for play (within school range = 14%–67%, assessed by returned calendars) b Restaurant healthy child menus 61 (54%) of the 112 restaurants approached agreed to create and modify a healthy menu for children (assessed by direct observation) a Posters, newsletters, frequent produce buyer cards in grocery stores Culturally appropriate media messages (SMHB) Four community Promotoras All participating teachers were asked to place posters in the classroom and distribute newsletter about healthy eating to students; frequent produce buyer cards were distributed throughout the community (3 years) Posters for healthy eating All six schools placed posters on healthy eatinga (assessed by direct observation) Distribution of newsletters 90% of teachers distributed newsletters to studentsa (assessed by audits of teacher mailboxes) Frequent produce buyer cards 7,800 buyer cards were distributed and 287 were returned completed (3.6%)a Components . Theoretical models/constructs . Delivery method/channel . Intended implementation frequency . Actual implementation frequency, mean ± SD, range . Family intervention Promotora home visits Health Belief Model Promotoras discussed with participants ways to overcome barriers to healthy eating and physical activity, ways to prepare healthy meals in the home, benefits of promoting healthy eating and PA in their children (e.g., behavioral benefits), ways to set appropriate goals for the family and monitor healthy eating in the home, and modeling healthy eating. 1 per month for 7 months (over one school year) Home visits Newsletters, recipe cards, goal setting Barriers 18% and 53% of participants received all 6 or all 7 visits, respectively Social Cognitive Theory Group mean = 5.5 ± 2.2 visits, range 0–7 (assessed by promotoras' tracking records) Behavioral Capability, Outcome Expectancies Self-Control, Modeling, and Self-efficacy Booster phone calls Discuss barriers (HBM) and Self-control (SCT) Promotoras called participants 4 calls over 2 years Booster Calls Goal setting, monitor progress 0 = 23%, 1 = 18%, 2 = 19%, 3 = 20%, 4 = 20% Group mean = 1.9 ± 1.5 calls, range 0–4 (assessed by promotoras' tracking records) Community intervention School playgrounds (improvements) and salad bars (implementation and improvement); community parks (improvements) Physical structure (SMHB) Four community Promotoras All playgrounds and salad bars from the six schools (for 3 years) Peaceful Playgrounds® All 6 schools improved their playgroundsa Salad bars at school cafeterias All six schools had salad bars, but none improved their displaya Community parks All community parks were assessed and only one was deemed as needing improvements. This park improveda. Teachers' discipline and classroom practices Social structure and policies (SMHB) Four community Promotoras All classrooms and teachers (3 years) Water bottles in classrooms 34% of classrooms in all six schools had visible water bottles (within school, range = 0%–63%, assessed by direct observation)b TAKE 10! 40% of teachers among all 6 schools reported using TAKE 10! (within school range was 23%–61%, assessed by returned calendars) a Home fun 31% of teachers among all six schools reported using Home Fun (within school range was 4–61%, assessed by returned calendars) a Physical education equipment, children's menus at restaurants Availability of protective/harmful products (SMHB) Four community Promotoras All classrooms and restaurants (3 years) Equipment for play 41% of classrooms in all 6 schools had equipment for play (within school range = 14%–67%, assessed by returned calendars) b Restaurant healthy child menus 61 (54%) of the 112 restaurants approached agreed to create and modify a healthy menu for children (assessed by direct observation) a Posters, newsletters, frequent produce buyer cards in grocery stores Culturally appropriate media messages (SMHB) Four community Promotoras All participating teachers were asked to place posters in the classroom and distribute newsletter about healthy eating to students; frequent produce buyer cards were distributed throughout the community (3 years) Posters for healthy eating All six schools placed posters on healthy eatinga (assessed by direct observation) Distribution of newsletters 90% of teachers distributed newsletters to studentsa (assessed by audits of teacher mailboxes) Frequent produce buyer cards 7,800 buyer cards were distributed and 287 were returned completed (3.6%)a SCT Social Cognitive Theory, HBM Health Belief Model, SMHB Structural Model of Health Behavior a Intervention component did not exist prior to Aventuras, thus any change reported was a result of Aventuras b Cross-sectional assessment at post-intervention (no baseline data available), thus cannot directly attribute change to Aventuras Open in new tab Table 1 Overview of multilevel intervention components, theoretical approach, and fidelity Components . Theoretical models/constructs . Delivery method/channel . Intended implementation frequency . Actual implementation frequency, mean ± SD, range . Family intervention Promotora home visits Health Belief Model Promotoras discussed with participants ways to overcome barriers to healthy eating and physical activity, ways to prepare healthy meals in the home, benefits of promoting healthy eating and PA in their children (e.g., behavioral benefits), ways to set appropriate goals for the family and monitor healthy eating in the home, and modeling healthy eating. 1 per month for 7 months (over one school year) Home visits Newsletters, recipe cards, goal setting Barriers 18% and 53% of participants received all 6 or all 7 visits, respectively Social Cognitive Theory Group mean = 5.5 ± 2.2 visits, range 0–7 (assessed by promotoras' tracking records) Behavioral Capability, Outcome Expectancies Self-Control, Modeling, and Self-efficacy Booster phone calls Discuss barriers (HBM) and Self-control (SCT) Promotoras called participants 4 calls over 2 years Booster Calls Goal setting, monitor progress 0 = 23%, 1 = 18%, 2 = 19%, 3 = 20%, 4 = 20% Group mean = 1.9 ± 1.5 calls, range 0–4 (assessed by promotoras' tracking records) Community intervention School playgrounds (improvements) and salad bars (implementation and improvement); community parks (improvements) Physical structure (SMHB) Four community Promotoras All playgrounds and salad bars from the six schools (for 3 years) Peaceful Playgrounds® All 6 schools improved their playgroundsa Salad bars at school cafeterias All six schools had salad bars, but none improved their displaya Community parks All community parks were assessed and only one was deemed as needing improvements. This park improveda. Teachers' discipline and classroom practices Social structure and policies (SMHB) Four community Promotoras All classrooms and teachers (3 years) Water bottles in classrooms 34% of classrooms in all six schools had visible water bottles (within school, range = 0%–63%, assessed by direct observation)b TAKE 10! 40% of teachers among all 6 schools reported using TAKE 10! (within school range was 23%–61%, assessed by returned calendars) a Home fun 31% of teachers among all six schools reported using Home Fun (within school range was 4–61%, assessed by returned calendars) a Physical education equipment, children's menus at restaurants Availability of protective/harmful products (SMHB) Four community Promotoras All classrooms and restaurants (3 years) Equipment for play 41% of classrooms in all 6 schools had equipment for play (within school range = 14%–67%, assessed by returned calendars) b Restaurant healthy child menus 61 (54%) of the 112 restaurants approached agreed to create and modify a healthy menu for children (assessed by direct observation) a Posters, newsletters, frequent produce buyer cards in grocery stores Culturally appropriate media messages (SMHB) Four community Promotoras All participating teachers were asked to place posters in the classroom and distribute newsletter about healthy eating to students; frequent produce buyer cards were distributed throughout the community (3 years) Posters for healthy eating All six schools placed posters on healthy eatinga (assessed by direct observation) Distribution of newsletters 90% of teachers distributed newsletters to studentsa (assessed by audits of teacher mailboxes) Frequent produce buyer cards 7,800 buyer cards were distributed and 287 were returned completed (3.6%)a Components . Theoretical models/constructs . Delivery method/channel . Intended implementation frequency . Actual implementation frequency, mean ± SD, range . Family intervention Promotora home visits Health Belief Model Promotoras discussed with participants ways to overcome barriers to healthy eating and physical activity, ways to prepare healthy meals in the home, benefits of promoting healthy eating and PA in their children (e.g., behavioral benefits), ways to set appropriate goals for the family and monitor healthy eating in the home, and modeling healthy eating. 1 per month for 7 months (over one school year) Home visits Newsletters, recipe cards, goal setting Barriers 18% and 53% of participants received all 6 or all 7 visits, respectively Social Cognitive Theory Group mean = 5.5 ± 2.2 visits, range 0–7 (assessed by promotoras' tracking records) Behavioral Capability, Outcome Expectancies Self-Control, Modeling, and Self-efficacy Booster phone calls Discuss barriers (HBM) and Self-control (SCT) Promotoras called participants 4 calls over 2 years Booster Calls Goal setting, monitor progress 0 = 23%, 1 = 18%, 2 = 19%, 3 = 20%, 4 = 20% Group mean = 1.9 ± 1.5 calls, range 0–4 (assessed by promotoras' tracking records) Community intervention School playgrounds (improvements) and salad bars (implementation and improvement); community parks (improvements) Physical structure (SMHB) Four community Promotoras All playgrounds and salad bars from the six schools (for 3 years) Peaceful Playgrounds® All 6 schools improved their playgroundsa Salad bars at school cafeterias All six schools had salad bars, but none improved their displaya Community parks All community parks were assessed and only one was deemed as needing improvements. This park improveda. Teachers' discipline and classroom practices Social structure and policies (SMHB) Four community Promotoras All classrooms and teachers (3 years) Water bottles in classrooms 34% of classrooms in all six schools had visible water bottles (within school, range = 0%–63%, assessed by direct observation)b TAKE 10! 40% of teachers among all 6 schools reported using TAKE 10! (within school range was 23%–61%, assessed by returned calendars) a Home fun 31% of teachers among all six schools reported using Home Fun (within school range was 4–61%, assessed by returned calendars) a Physical education equipment, children's menus at restaurants Availability of protective/harmful products (SMHB) Four community Promotoras All classrooms and restaurants (3 years) Equipment for play 41% of classrooms in all 6 schools had equipment for play (within school range = 14%–67%, assessed by returned calendars) b Restaurant healthy child menus 61 (54%) of the 112 restaurants approached agreed to create and modify a healthy menu for children (assessed by direct observation) a Posters, newsletters, frequent produce buyer cards in grocery stores Culturally appropriate media messages (SMHB) Four community Promotoras All participating teachers were asked to place posters in the classroom and distribute newsletter about healthy eating to students; frequent produce buyer cards were distributed throughout the community (3 years) Posters for healthy eating All six schools placed posters on healthy eatinga (assessed by direct observation) Distribution of newsletters 90% of teachers distributed newsletters to studentsa (assessed by audits of teacher mailboxes) Frequent produce buyer cards 7,800 buyer cards were distributed and 287 were returned completed (3.6%)a SCT Social Cognitive Theory, HBM Health Belief Model, SMHB Structural Model of Health Behavior a Intervention component did not exist prior to Aventuras, thus any change reported was a result of Aventuras b Cross-sectional assessment at post-intervention (no baseline data available), thus cannot directly attribute change to Aventuras Open in new tab Family/Home (Family-Only) Intervention Family intervention activities (see Table 1) were delivered by eight promotoras who were recruited and selected through schools to ensure their intimate knowledge of relevant neighborhood resources and barriers. Additional inclusion criteria for the promotoras included female gender, willingness to commit to the project for at least one academic year, ability to speak and read Spanish, access to personal transportation, and ability to read and write at an eighth grade level or higher (in Spanish). Candidates were screened using a self-administered application form to assess literacy, followed by an interview to assess important attributes such as approachability, willingness to learn new skills, familiarity with the target community area, appreciation of the importance of preventing childhood obesity, previous community work, and availability to work 15–20 h per week. Promotoras received 22 h of training delivered over 11 sessions using a project-developed curriculum on changing parenting and other aspects of the home environment, childhood obesity, and child nutrition and physical activity needs. The curriculum was informed by previous studies in Latino populations [33–35, 37, 38], as well as Applied Behavioral Analysis [39]. Promotora training included an orientation to the structure of and materials for the family home visits, as well as opportunities to role-play. Biweekly meetings occurred throughout the intervention period to continue promotora skill building, problem-solve difficult situations, and to provide positive reinforcement for completed work. On any given month, each promotora worked with 12 to 30 families depending on her availability. The promotoras were reimbursed for their travel and time involved in the study. Information on the components of the Family-only intervention is found in Table 1. Key behaviors targeted during the discussions focused on increasing fruit, vegetable, and water consumption, increasing active play and decreasing sugar-sweetened beverages and TV viewing. Targeted environmental changes included having cut-up vegetables within a child's reach and moving a TV out of a child's bedroom, as well as contingency management such as rules and boundaries set by parents, discipline methods and use of positive reinforcement. When promotora turnover required that a new promotora be assigned to the family, she was given a folder with notes from all previous family contacts to ensure consistency. During the course of the study, 19% of families opted to discontinue in-home visits due to time constraints and subsequently switched to mailed newsletters. School/Community (Community-Only) Intervention In accordance with the Structural Model of Health Behavior [40], the Community-only intervention was designed to alter physical structures (e.g., playgrounds and cafeteria salad bars), social structures, and policies (e.g., teachers' discipline, classroom practices, and public park maintenance), availability of protective or harmful products (e.g., physical education equipment and healthy children's menus in restaurants), and culturally appropriate media messages (e.g., posters, newsletters and point-of-choice messages in grocery stores) (see Table 1). Some of the community environmental changes were directly implemented by Aventuras staff and promotoras, while others were aimed at adults (including principals, teachers, foodservice workers, restaurant owners, grocery store managers, and local government officials) who controlled aspects of the children's daily environments outside of the home. Community-only intervention promotoras were unaware of whether students at a given school were enrolled in the study. Information was provided to the entire school, particularly the target grade levels, and to the community at large. Given their slowly developing iterative nature, these school programs and community change efforts lasted 3 years, building or at least maintaining strength over that period rather than tapering down to a “booster” level such as in the Family-only condition. The number of community intervention promotoras varied from six to nine, with a final core group of four. Community-only intervention promotoras received two 8-h training sessions that included the same basic information as in the Family-only intervention promotora training, as well as details of the environmental change goals for the schools, an overview of community organizing techniques, and possible community change goals. Ongoing weekly meetings were held with the community intervention promotoras to provide additional skills trainings, redirection, encouragement, and positive reinforcement. As with the Family-only intervention, the school component of the Community-only intervention targeted policies and practices as well as physical structures that shape children's choices. For instance, methods of teaching Physical Education and the types of encouragement children received in making lunch choices were addressed, along with the physical availability of Physical Education equipment and access to a well-stocked salad bar during lunchtime. In the classroom, academic content was incorporated wherever possible to help teachers see the intervention as an enhancement rather than an interruption of the required curricula. The school intervention included several previously developed programs such as a Physical Education program based on SPARK [41], Peaceful Playgrounds® [42], and Take 10!® [43]. Aventuras staff provided follow-up to school staff to reinforce the continued use of the programs and also developed a number of new school interventions, including Start with Salad, which used posters and stickers to encourage vegetable consumption at lunch, Home Fun, and Healthy Classrooms [39]. For the Home Fun program, teachers handed out calendars with daily activities for both physical activity and nutrition as homework assignments. Parents were asked to initial each day that their child completed the activity. For the Healthy Classrooms program, teachers were encouraged to make healthy changes to their classroom environments and policies, such as incorporating non-food rewards, disciplining students in ways that did not remove opportunities for physical activity, providing healthy food options during classroom parties/celebrations, and increasing access to drinking water during the school day. In the six schools assigned to the Community-only and Family + Community intervention conditions, all teachers in the target grades participated in a teacher training session at the beginning of the school year. For example, in year 1, all teachers in grades K-2 participated in the training sessions, and by year 2 of the study, third-grade teachers received trainings to maintain the dose intensity that was to follow each cohort. Teachers received a shortened SPARK Physical Education curriculum and group training (approximately 4 h) in Physical Education teaching methods. The group trainings were followed by individual model teaching sessions (30 min per teacher), in which the trainer taught each teacher's Physical Education class while the teacher observed, participated, and asked questions. In addition to the modified SPARK training, teachers received a brief training on the Take 10!® program, Peaceful Playgrounds®, Home Fun, and Healthy Classrooms (ranged from 60 to 90 min). Teachers received a training manual that described each program and were given related materials and activities. Food service workers at each school were trained by the study's registered dietitian on the importance of keeping the salad bars clean and well stocked with fresh produce and on prompting children to select and eat vegetables and fruit for the Start with Salad program. Cafeteria workers were asked to help the promotoras with the program by giving children colorful stickers that served as an incentive for them to eat salad or vegetables first when they sat down to eat lunch. Annual booster trainings were conducted at each school to train new teachers and staff and reinforce previously trained teachers and staff. As part of the community component of the Community-only intervention, the promotoras received a list of restaurants derived from a county health department list and verified by direct observation by research assistants with GPS units. The promotoras approached 153 locally owned restaurants within a 1-mile radius of each of the six intervention schools, and suggested a collaboration to create a healthy children's menu. When restaurant owners agreed, the promotoras worked with them to develop menus that fit with the existing ones and met the following guidelines: smaller portions than the regular menu, lower prices, vegetable or fruit side dishes rather than French fries, fewer fried foods, and healthy beverage offerings, or preferably, replacing the choice of sodas. The restaurants received color copies of the menus in English and Spanish and in various sizes, as well as posters to display in windows. Some were laminated for repeated distribution to patrons, and some were placed in table stands, along with a wall certificate and laminated window signs announcing the new menus. The promotoras continued to visit the restaurants regularly to assess adherence and adoption and to check whether changes were needed in the menus. Participating restaurants received publicity in Aventuras school newsletters, and a list and description of the restaurants and coupons promoting the new children's menus were circulated throughout the community. This effort focused on locally owned restaurants as managers of fast food and other chain restaurants indicated that any menu changes had to be decided by their corporate offices which was not feasible to pursue given the study timeline and limited resources. Initial contacts with 153 restaurants began in October 2004 with all but two of the restaurants serving Mexican cuisine. Most did not have a children's menu, and those that did had no side dishes except French fries listed for children. In a second component of the Community-only intervention, Aventuras staff and promotoras developed a program of “frequent produce buyer cards” for local grocery stores. About 7,800 wallet-sized cards were distributed to shoppers and families at participating intervention schools who could present them at the grocery store “check-out” to be marked each time they bought fresh fruits or vegetables. After nine separate purchases, the shopper received one free pound of fresh fruits or vegetables. The message, “Eat fruits and vegetables and be active,” and brief information about the California Food Stamps program was printed on the back of each card in English and Spanish. In collaboration with Latino 5-a-Day, fairs were conducted at each participating grocery store with free giveaways, food demonstrations and tastings, and raffles. The promotoras proposed the program to the owners or managers of grocery stores near the intervention schools especially where study participants reported shopping. The most positive response was from locally owned businesses. In terms of changes to the community environment to promote physical activity, one of the first goals identified by the promotoras was to improve local parks to make them more accessible and attractive to local families. Several parks in San Ysidro, the southernmost portion of the City of San Diego at the US–Mexico border, were in particularly bad condition with few play structures or picnic tables, broken, non-functioning, graffiti-covered playground equipment, non-functioning water fountains and bathrooms, and insufficient lighting. Two promotoras took photos of the physical conditions of four of the parks, interviewed families, and obtained more than 300 signatures on a petition for improvements, which was presented to the San Diego City Council. In addition, two apartment complex managers were contacted of apartment complexes where a large number of Community-only condition participants resided. The promotoras suggested easing restrictions on children's ability to engage in outdoor activity as parents reported having been told to keep children out of common areas and, hence, indoors. Other school and community-level interventions, including cooking classes and “walking school buses” [44], were not well received by the target audience and were not pursued. Control Condition The control condition consisted of measures only. Participants in the control condition were asked to maintain their regular lifestyles and to complete the yearly measurements. Evaluation Procedures Data were collected at four time points, beginning during the 2003–2004 school year: baseline (M1), immediate 1-year post-intervention (M2), 1-year follow-up (M3), and 2-year follow-up (M4). Parents completed a self-administered survey available in Spanish and English at their child's school or in their home. Bilingual and bicultural evaluation assistants were available to ensure that participants understood the survey questions and to measure the child's and parent's height and weight. Measurement staff were blinded to participants' study condition. Measures Parent and Child BMI Parent and child height and weight were measured with a portable stadiometer and digital scale according to standard anthropometric procedures [45]. Parent and child BMI (kilograms per square meter) was calculated and child BMI-for-age and gender (z-score and percentile) was calculated based on the 2000 Centers for Disease Control and Prevention (CDC) growth charts [46]. Twenty percent of the anthropometric measurements were randomly selected for reliability assessments (inter-rater reliability was 97–99%). Children's Physical Activity Parents were asked “Compared to children of the same age and sex, how much physical activity does your child get?”. Response options ranged from “1 = much less than others” to “5 = much more than others.” In previous research, this measure was independently and inversely associated with child BMI z-score [35]. Children's Sports Participation Parents were asked “During the past year, did your child participate in any youth team sports or clubs?” A summary variable represented the total number of team sports that the child participated in during the past year. This measure was developed by the study team. Past research showed that overweight children who participate in afterschool team sports achieve reductions in BMI z-score [47]. Active Transportation to and from School Parents were asked “In a typical week, how many days does your child get to school by…” and “…get home from school by…” The sum of all days the child traveled to and from school by “walking, riding a bicycle, or skateboard” was computed. This measure was developed by the study team. Research shows that active transport to school is associated with lower BMI in children [48]. Availability and Use of Active Toys Availability and use of activity-promoting toys was assessed by asking the parent to indicate which toys, from a checklist, were available and used by their child. The list of toys included 12 items such as a bicycle, roller skates, balls, Frisbees, etc., and a sum score was created from all toys selected by the parent. This measure was developed by the study team. Past research shows that fixed and portable play equipment is associated with greater child physical activity [49]. Parental Support for Child Physical Activity Support was measured with three questions: “On how many days do you 1) provide encouragement, 2) provide transportation, and/or 3) actively participate in physical activity with your child?” Response options ranged from 1 to 7 days a week. A total instrumental support score was created by summing the responses to the three questions (α = 0.72). Previous analyses indicated that frequency of parental support was associated with perceptions that the child was more physically active than his/her peers [17]. TV Viewing Parents reported how often the child viewed TV while getting ready for school, from 1 = never to 5 = always. TV viewing while eating dinner was assessed with one question, from 1 = never to 5 = very often. Both questions were developed in a previous study with the target population and the latter was found to be related to child's dietary intake [50]. Children's Dietary Intake A 49-item food frequency questionnaire assessed children's dietary intake. Parents rated how often their child consumed each food item, with response options ranging from 1 = never to 10 = five or more times per day. Item responses were recoded into number of daily servings. Food items included in the survey were identified from previous studies with the target population [51]. Four dietary intake variables were created: number of daily servings of sodas and other sugar-sweetened beverages, number of daily servings of water, number of daily servings of sweet and savory snacks/desserts, and number of daily servings of fruits and vegetables. Parenting Style for Diet and Activity Parenting style was measured with a 26-item scale developed for this project [52], consisting of five subscales: limit setting (six items), monitoring (seven items), discipline (five items), control (six items), and reinforcement (two items). Response options include frequency (e.g., monitoring: 1 = never to 5 = always) and strength of agreement (e.g., discipline: 1 = strongly disagree to 5 = strongly agree) options, with a mean score calculated for each subscale (α ranged from 0.73 to 0.87). Behavioral Strategies for Fat and Fiber A 30-item scale was used to assess parent behavioral strategies to reduce fat (19 items; α = 0.73) and increase fiber (11 items; α = 0.76). This scale was developed for use in a previous study [52] and has acceptable construct and predictive validity [53]. Family Meals Together Parents were asked “Which of the following meals does your family eat together at least four or more days per week?” A sum score was generated by summing the ‘yes’ responses to breakfast, lunch, and dinner. This measure was developed in a previous study by the study team that showed a positive association between the number of family meals eaten together and children's fiber consumption [54]. Other research shows that eating fewer family meals is associated with greater likelihood of child overweight [55]. Away-From-Home Eating This dietary behavior was measured with five questions developed in a previous study [56] that asked how frequently (from 1 = never to 5 = five to seven times per week) families ate away-from-home foods from: relatives' homes, neighbors'/friends' homes, sit down restaurants, fast food restaurants, and restaurants in Mexico. Responses were dichotomized to reflect whether the family consumed away-from-home foods at least once a week or more in each context based on evidence linking weekly consumption with BMI [56]. A final summary score reflected the number of locations where away-from-home foods were consumed at least weekly. Demographic Variables Parents reported on the following demographic information: parent and child age (in years) and gender, marital status (married or living as married vs. not married), household income (less than or greater than $1,720/month), homeownership (yes/no), household size (open-ended), level of education (≤ high school vs. > high school), employment status (employed vs. unemployed), and parent and child generation status. Statistical Analysis Outcome Analyses All analyses were based on the intention-to-treat approach. Each outcome was examined using mixed effects models for normal outcomes (SAS Proc Mixed) or generalized linear mixed effects models for non-normal outcomes (SAS Proc Glimmix). For non-normal outcomes, appropriate error distribution and link functions were chosen according to the type of outcome. For dichotomous variables (e.g., any youth sport team participation), a logistic-type model was used with a binomial error and logit link. For counting outcomes (e.g., total number of fruits and vegetables per day or total number of snacks per day), either a Poisson or negative binomial regression was chosen according to which provided the best model fit. Models accounted for repeated measures over M2 to M4 and adjusted for the M1 (baseline) level. All available data were utilized. Thus, although a participant may have data missing at M2, M3, or M4, data available at non-missing time points were still included in the analysis. All models adjusted for parent gender, language of survey, parent age, marital status, household size, employment status, education status, homeownership, parent income, child gender, child age, and child generation status. In addition, all models adjusted for clustering at the school level. With one exception, the intraclass correlations (ICC) for the outcome measures ranged from 0 to 0.019. These ICCs were well within the range anticipated by the study based on published estimates of other school-based studies [57]. The lone exception was number of snacks consumed per day with an ICC of 0.095. Terms were included in the model to account for the study design consisting of a 2 × 2 factorial (Family-only: ‘yes’ vs. ‘no’ and Community-only: ‘yes’ vs. ‘no’) and to account for study time trends. Modeling began with a model including the Time-by-Family-by-Community interaction and all lower order terms. Non-significant terms (p > .05) were eliminated in a hierarchical manner. Mediation Analyses The mediation analyses procedures outlined by MacKinnon et al. [58, 59] were followed. Mediators are intervening factors that are amenable to change and that explain the relationship between the intervention and the outcome of interest. As such, the intervention was hypothesized to change the mediators, which in turn change the outcome variable. Three regression models were fitted yielding the necessary parameter estimates and standard errors. First, the intervention effect was examined on each outcome variable (carried out in this paper). Second, the intervention effect was examined on each parent mediator (based, in part, on a previous paper from these data) [60]. Based on the results of these analyses, outcomes and potential mediators were selected for further evaluation. Results from both models focused on the Family-only intervention main effect as the primary significant effect of interest. Finally, for each outcome, the intervention effect and each potential mediator were included in the same model. All models adhered to the study design and accounted for the multilevel structure of the data. All models adjusted for the same set of covariates. As described by MacKinnon et al. [58], the mediated effect is the result of the product of the unstandardized regression coefficient of the intervention effect in model 2 (coefficient a) and the unstandardized coefficient of the potential mediator in model 3 adjusted for the intervention effect (coefficient b). This product, ‘ab’, is usually assumed to be normally distributed and its significance is often evaluated using Sobel's test. However, ‘ab’ is usually highly skewed and does not follow a normal distribution. MacKinnon et al. [59] developed software that provides more accurate asymmetric confidence limits for the product than that provided by Sobel's test. A significant mediated effect at a level of significance of .05 is determined if the confidence interval does not include 0. The software, PRODCLIN, is available as a SAS macro. Power Calculation The total sample size at year 3 (i.e., M4) was 441, although all participants who contributed at least one measure at M2 through M4 were included in the analyses. Nevertheless, a power calculation was done relative to our hypothesized effect sizes based on a 3-year follow-up. Our effects sizes were based on data from Rosner et al. [61] tracking BMI changes in 5 to 8 year old Latino children over 3 years. The average change was 1.99 kg/m2. This natural change is what we expected to observe in the control condition. Although we examined a number of scenarios, the most conservative scenario assumed no increase in BMI in the Family and Community intervention condition over the 3-year period. We assumed that the difference between the control condition and the Family and Community intervention condition would be driven largely by the Family intervention, responsible for 2/3 of the change, and the Community intervention responsible for 1/3. Consequently, the Family main effect was assumed to be 1.33 kg/m2 and the Community main effect of 0.66 kg/m2. We did not hypothesize a specific interaction effect since we had no available information to justify a specific effect size. Utilizing an estimated standard deviation of 2.02 kg/m2, the standardized effect sizes were hypothesized to be 0.66 for the Family main effect and 0.33 for the Community main effect. The clustering attributed to schools yielded ICCs ranging from 0 to 0.016 depending on outcome. Therefore, 0.016 was used to account for school clustering. Based on the information above and a significance level of 0.05 (two-sided), power to detect the Community intervention main effect was 80% and power to detect the Family intervention main effect was 97%. Results Participant Characteristics and Retention Rates Primary analyses were based on data from baseline (M1) to three-year follow-up (M4) representing an overall retention rate of 55% and condition-specifıc retention rates of 48% (Family-only), 50% (Family + Community), 59% (Community-only), and 59% (control). Figure 1 depicts the study CONSORT flow diagram [62]. Baseline results, including a detailed description of participant characteristics for the Aventuras study have been previously published [35]. Briefly, parent's mean age was 33 ± 6 years, 95% female, 71% were married/living as married, 67% completed high school or less, 72% were foreign-born, 29.7 ± 6.7 mean BMI (kilograms per square meter), 33.8% were overweight, and 41.3% were obese. Children were aged 5.9 ± 0.9 years, 50% were girls, 86% were US-born, 17% were overweight, and 29.5% were obese [35]. Analyses were carried out to determine if baseline measures of outcomes were different between participants who completed the study versus those who dropped out across the four study conditions. Mixed effects models were fitted for each baseline outcome measure with terms in the model for dropout status, group condition and dropout by group condition interaction. The interaction term would determine whether baseline levels across groups varied by dropout status. None of the models found significant interaction terms. Fig. 1 Open in new tabDownload slide Participant flow chart following Consolidated Standards of Reporting Trial Guidelines. M = Measurement time point; MTP = Missing time point; LTF = Lost to follow-up. Family-only = Family only intervention; Community-only = Community intervention; Family+Community = Family-plus-Community intervention. Figure conforms to the recommended reporting standards for randomized trials CONSORT flow charts [62] Intervention Effects Table 2 shows the child BMI z-scores, percentiles, and proportions of children in the overweight and obese categories by study condition at all time points. No changes in any of these weight measures were statistically significant. Children in all conditions increased their overall mean BMI z-score over the course of the study. The proportion of children classified as obese (≥95th percentile weight for age) increased in all except the Family-only condition at the final measurement (M4); however, this and the Community-only condition evidenced the greatest increase in the overweight category (≥85th <95th percentile). There were also no significant intervention effects on parent BMI or BMI category (data not shown). After adding interaction terms to the models, there was no evidence that intervention effects varied by child's baseline weight status or child's gender. Table 2 Descriptive statistics for child body mass index (BMI) z-score, BMI percentile, and weight category . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . BMI z-score M1 0.86 1.12 0.94 1.23 0.87 1.11 1.00 1.10 M2 0.86 1.06 0.95 1.13 0.85 1.09 0.99 1.12 M3 0.94 0.99 1.01 1.08 0.93 1.01 1.03 1.08 M4 0.95 1.05 1.00 1.04 0.99 1.05 0.97 1.09 BMI percentile M1 72.15 27.28 72.64 27.30 72.15 26.87 74.84 25.50 M2 72.63 26.26 73.83 26.43 71.71 27.00 74.07 27.04 M3 75.43 23.81 74.66 25.76 74.23 25.60 75.41 25.81 M4 74.62 25.85 75.08 25.48 75.49 26.67 73.51 27.24 OW Obese OW Obese OW Obese OW Obese Weight category M1 19% 27% 14% 31% 19% 28% 18% 31% M2 17% 27% 17% 29% 19% 26% 17% 33% M3 21% 26% 22% 29% 21% 27% 17% 35% M4 18% 32% 23% 30% 20% 35% 13% 35% . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . BMI z-score M1 0.86 1.12 0.94 1.23 0.87 1.11 1.00 1.10 M2 0.86 1.06 0.95 1.13 0.85 1.09 0.99 1.12 M3 0.94 0.99 1.01 1.08 0.93 1.01 1.03 1.08 M4 0.95 1.05 1.00 1.04 0.99 1.05 0.97 1.09 BMI percentile M1 72.15 27.28 72.64 27.30 72.15 26.87 74.84 25.50 M2 72.63 26.26 73.83 26.43 71.71 27.00 74.07 27.04 M3 75.43 23.81 74.66 25.76 74.23 25.60 75.41 25.81 M4 74.62 25.85 75.08 25.48 75.49 26.67 73.51 27.24 OW Obese OW Obese OW Obese OW Obese Weight category M1 19% 27% 14% 31% 19% 28% 18% 31% M2 17% 27% 17% 29% 19% 26% 17% 33% M3 21% 26% 22% 29% 21% 27% 17% 35% M4 18% 32% 23% 30% 20% 35% 13% 35% OW = overweight, Family-only Family intervention, Community-only Community intervention, Family + Community Family-plus-Community intervention Open in new tab Table 2 Descriptive statistics for child body mass index (BMI) z-score, BMI percentile, and weight category . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . BMI z-score M1 0.86 1.12 0.94 1.23 0.87 1.11 1.00 1.10 M2 0.86 1.06 0.95 1.13 0.85 1.09 0.99 1.12 M3 0.94 0.99 1.01 1.08 0.93 1.01 1.03 1.08 M4 0.95 1.05 1.00 1.04 0.99 1.05 0.97 1.09 BMI percentile M1 72.15 27.28 72.64 27.30 72.15 26.87 74.84 25.50 M2 72.63 26.26 73.83 26.43 71.71 27.00 74.07 27.04 M3 75.43 23.81 74.66 25.76 74.23 25.60 75.41 25.81 M4 74.62 25.85 75.08 25.48 75.49 26.67 73.51 27.24 OW Obese OW Obese OW Obese OW Obese Weight category M1 19% 27% 14% 31% 19% 28% 18% 31% M2 17% 27% 17% 29% 19% 26% 17% 33% M3 21% 26% 22% 29% 21% 27% 17% 35% M4 18% 32% 23% 30% 20% 35% 13% 35% . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . BMI z-score M1 0.86 1.12 0.94 1.23 0.87 1.11 1.00 1.10 M2 0.86 1.06 0.95 1.13 0.85 1.09 0.99 1.12 M3 0.94 0.99 1.01 1.08 0.93 1.01 1.03 1.08 M4 0.95 1.05 1.00 1.04 0.99 1.05 0.97 1.09 BMI percentile M1 72.15 27.28 72.64 27.30 72.15 26.87 74.84 25.50 M2 72.63 26.26 73.83 26.43 71.71 27.00 74.07 27.04 M3 75.43 23.81 74.66 25.76 74.23 25.60 75.41 25.81 M4 74.62 25.85 75.08 25.48 75.49 26.67 73.51 27.24 OW Obese OW Obese OW Obese OW Obese Weight category M1 19% 27% 14% 31% 19% 28% 18% 31% M2 17% 27% 17% 29% 19% 26% 17% 33% M3 21% 26% 22% 29% 21% 27% 17% 35% M4 18% 32% 23% 30% 20% 35% 13% 35% OW = overweight, Family-only Family intervention, Community-only Community intervention, Family + Community Family-plus-Community intervention Open in new tab Secondary Behavioral Outcomes Tables 3 and 4 display descriptive statistics for secondary behavioral outcomes. Table 5 shows the specific intervention effects for several of these outcomes. The Family-only intervention significantly increased parent-reported child physical activity, reduced child frequency of watching TV when getting ready for school, increased child's daily consumption of fruits and vegetables, and increased behavioral strategies for fat (all significant Family-only intervention main effects). There was no main effect of the Community-only intervention for any of the outcomes. There was a significant Time-by-Community interaction for child snacks consumed per day. There was a significant Community-by-Family interaction for child participation in number of team sports. The significant Time-by-Family-by-Community interaction for parents' use of dietary behavioral strategies to reduce fat was due to the strong community intervention effect at M2 and M3 that diminished at M4. A significant three-way effect for water consumption was difficult to interpret. Although at M3 there was an indication of higher consumption among children in the combined Family + Community group, this effect was not replicated at M2 or M4. Consumption of sugary-sweetened beverages also had a significant three-way effect. At M2 children in the combined Family + Community group had a lower mean count than the other three groups, but this pattern diminished at M3 and M4. No intervention effects were observed for dietary behavioral strategies to increase fiber, child active transport to and from school, child participation in any team sports or use of activity-promoting toys (i.e., none of the interaction terms were significant). Table 3 Descriptive statistics for child consumption of fruits and vegetables, snacks, sugar-sweetened beverages, and water, and parent behavioral strategies for fat . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . F&V M1 1.90 3.19 1.89 2.66 1.69 2.45 1.80 2.72 M2 2.04 2.54 2.19 2.50 1.50 2.03 1.68 2.41 M3 2.45 2.90 2.30 2.82 1.99 2.88 1.93 2.73 M4 2.22 2.85 2.31 2.86 1.84 2.03 2.27 2.64 Snacks MI 1.39 2.85 1.74 3.81 1.39 3.47 1.51 3.48 M2 0.45 1.56 1.11 3.17 0.71 1.70 1.44 3.77 M3 1.25 3.37 0.69 1.65 1.47 3.65 1.11 2.95 M4 0.95 3.16 1.64 4.87 1.02 2.59 1.04 2.54 SSBs M1 0.78 1.37 0.88 1.59 0.83 1.71 0.88 1.65 M2 0.39 1.12 0.58 1.30 0.56 1.26 0.83 1.64 M3 0.49 1.38 0.50 1.24 0.56 1.20 0.60 1.20 M4 0.38 1.25 0.56 1.26 0.67 1.25 0.39 0.97 Water M1 2.69 1.95 2.68 1.90 2.51 1.82 2.44 1.85 M2 2.68 1.87 3.12 1.74 2.60 1.86 2.76 1.83 M3 2.90 1.87 2.57 1.92 2.76 1.86 2.93 1.77 M4 2.91 1.82 3.00 1.83 3.23 1.66 2.87 1.78 Behavioral M1 2.58 0.56 2.57 0.59 2.57 0.56 2.56 0.58 Strategies: fat M2 2.89 0.57 2.87 0.59 2.76 0.60 2.71 0.53 M3 2.89 0.55 2.89 0.56 2.76 0.60 2.82 0.56 M4 2.85 0.53 2.92 0.55 2.87 0.60 2.72 0.58 . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . F&V M1 1.90 3.19 1.89 2.66 1.69 2.45 1.80 2.72 M2 2.04 2.54 2.19 2.50 1.50 2.03 1.68 2.41 M3 2.45 2.90 2.30 2.82 1.99 2.88 1.93 2.73 M4 2.22 2.85 2.31 2.86 1.84 2.03 2.27 2.64 Snacks MI 1.39 2.85 1.74 3.81 1.39 3.47 1.51 3.48 M2 0.45 1.56 1.11 3.17 0.71 1.70 1.44 3.77 M3 1.25 3.37 0.69 1.65 1.47 3.65 1.11 2.95 M4 0.95 3.16 1.64 4.87 1.02 2.59 1.04 2.54 SSBs M1 0.78 1.37 0.88 1.59 0.83 1.71 0.88 1.65 M2 0.39 1.12 0.58 1.30 0.56 1.26 0.83 1.64 M3 0.49 1.38 0.50 1.24 0.56 1.20 0.60 1.20 M4 0.38 1.25 0.56 1.26 0.67 1.25 0.39 0.97 Water M1 2.69 1.95 2.68 1.90 2.51 1.82 2.44 1.85 M2 2.68 1.87 3.12 1.74 2.60 1.86 2.76 1.83 M3 2.90 1.87 2.57 1.92 2.76 1.86 2.93 1.77 M4 2.91 1.82 3.00 1.83 3.23 1.66 2.87 1.78 Behavioral M1 2.58 0.56 2.57 0.59 2.57 0.56 2.56 0.58 Strategies: fat M2 2.89 0.57 2.87 0.59 2.76 0.60 2.71 0.53 M3 2.89 0.55 2.89 0.56 2.76 0.60 2.82 0.56 M4 2.85 0.53 2.92 0.55 2.87 0.60 2.72 0.58 F&V = total number of fruits and vegetables child consumes per day in a typical week; Snacks = total number of snacks child consumes per day in a typical week; SSBs = total number of sugar-sweetened beverages child drinks per day in a typical week; Water = total number of glasses of water child drinks per day on a typical week; and Behavioral Strategies: Fat = total number of behavioral strategies parent uses to reduce fat in family's diet. All analyses were adjusted for parent gender, language of survey, survey version, parent age, marital status, household size, employment status, education status, homeownership status, parent income, child gender, child age, and child generation status; Family-only = Family intervention; Community-only = Community intervention; Family + Community = Family-plus-Community intervention Open in new tab Table 3 Descriptive statistics for child consumption of fruits and vegetables, snacks, sugar-sweetened beverages, and water, and parent behavioral strategies for fat . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . F&V M1 1.90 3.19 1.89 2.66 1.69 2.45 1.80 2.72 M2 2.04 2.54 2.19 2.50 1.50 2.03 1.68 2.41 M3 2.45 2.90 2.30 2.82 1.99 2.88 1.93 2.73 M4 2.22 2.85 2.31 2.86 1.84 2.03 2.27 2.64 Snacks MI 1.39 2.85 1.74 3.81 1.39 3.47 1.51 3.48 M2 0.45 1.56 1.11 3.17 0.71 1.70 1.44 3.77 M3 1.25 3.37 0.69 1.65 1.47 3.65 1.11 2.95 M4 0.95 3.16 1.64 4.87 1.02 2.59 1.04 2.54 SSBs M1 0.78 1.37 0.88 1.59 0.83 1.71 0.88 1.65 M2 0.39 1.12 0.58 1.30 0.56 1.26 0.83 1.64 M3 0.49 1.38 0.50 1.24 0.56 1.20 0.60 1.20 M4 0.38 1.25 0.56 1.26 0.67 1.25 0.39 0.97 Water M1 2.69 1.95 2.68 1.90 2.51 1.82 2.44 1.85 M2 2.68 1.87 3.12 1.74 2.60 1.86 2.76 1.83 M3 2.90 1.87 2.57 1.92 2.76 1.86 2.93 1.77 M4 2.91 1.82 3.00 1.83 3.23 1.66 2.87 1.78 Behavioral M1 2.58 0.56 2.57 0.59 2.57 0.56 2.56 0.58 Strategies: fat M2 2.89 0.57 2.87 0.59 2.76 0.60 2.71 0.53 M3 2.89 0.55 2.89 0.56 2.76 0.60 2.82 0.56 M4 2.85 0.53 2.92 0.55 2.87 0.60 2.72 0.58 . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . F&V M1 1.90 3.19 1.89 2.66 1.69 2.45 1.80 2.72 M2 2.04 2.54 2.19 2.50 1.50 2.03 1.68 2.41 M3 2.45 2.90 2.30 2.82 1.99 2.88 1.93 2.73 M4 2.22 2.85 2.31 2.86 1.84 2.03 2.27 2.64 Snacks MI 1.39 2.85 1.74 3.81 1.39 3.47 1.51 3.48 M2 0.45 1.56 1.11 3.17 0.71 1.70 1.44 3.77 M3 1.25 3.37 0.69 1.65 1.47 3.65 1.11 2.95 M4 0.95 3.16 1.64 4.87 1.02 2.59 1.04 2.54 SSBs M1 0.78 1.37 0.88 1.59 0.83 1.71 0.88 1.65 M2 0.39 1.12 0.58 1.30 0.56 1.26 0.83 1.64 M3 0.49 1.38 0.50 1.24 0.56 1.20 0.60 1.20 M4 0.38 1.25 0.56 1.26 0.67 1.25 0.39 0.97 Water M1 2.69 1.95 2.68 1.90 2.51 1.82 2.44 1.85 M2 2.68 1.87 3.12 1.74 2.60 1.86 2.76 1.83 M3 2.90 1.87 2.57 1.92 2.76 1.86 2.93 1.77 M4 2.91 1.82 3.00 1.83 3.23 1.66 2.87 1.78 Behavioral M1 2.58 0.56 2.57 0.59 2.57 0.56 2.56 0.58 Strategies: fat M2 2.89 0.57 2.87 0.59 2.76 0.60 2.71 0.53 M3 2.89 0.55 2.89 0.56 2.76 0.60 2.82 0.56 M4 2.85 0.53 2.92 0.55 2.87 0.60 2.72 0.58 F&V = total number of fruits and vegetables child consumes per day in a typical week; Snacks = total number of snacks child consumes per day in a typical week; SSBs = total number of sugar-sweetened beverages child drinks per day in a typical week; Water = total number of glasses of water child drinks per day on a typical week; and Behavioral Strategies: Fat = total number of behavioral strategies parent uses to reduce fat in family's diet. All analyses were adjusted for parent gender, language of survey, survey version, parent age, marital status, household size, employment status, education status, homeownership status, parent income, child gender, child age, and child generation status; Family-only = Family intervention; Community-only = Community intervention; Family + Community = Family-plus-Community intervention Open in new tab Table 4 Descriptive statistics for child physical activity, sports participation, and TV viewing . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . Child PA M1 3.11 0.85 2.98 0.81 2.97 0.91 3.00 0.90 M2 3.47 0.72 3.28 0.80 3.18 0.86 3.05 0.85 M3 3.36 0.92 3.36 0.85 3.13 0.85 3.14 0.83 M4 3.41 0.84 3.15 0.80 3.06 0.91 3.28 0.89 Sports MI 0.70 0.98 0.65 0.85 0.92 0.97 1.05 1.10 M2 1.87 1.29 1.50 1.03 1.26 0.89 1.46 1.05 M3 1.75 1.26 1.95 1.36 1.42 0.92 1.78 1.08 M4 1.81 1.50 1.92 1.01 1.49 1.04 2.05 1.36 TV viewing M1 2.21 1.29 2.05 1.22 2.10 1.23 2.10 1.21 M2 – – – – – – – – M3 1.99 1.27 1.95 1.09 2.18 1.23 2.04 1.12 M4 1.69 0.97 1.76 0.94 2.04 1.22 2.09 1.22 . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . Child PA M1 3.11 0.85 2.98 0.81 2.97 0.91 3.00 0.90 M2 3.47 0.72 3.28 0.80 3.18 0.86 3.05 0.85 M3 3.36 0.92 3.36 0.85 3.13 0.85 3.14 0.83 M4 3.41 0.84 3.15 0.80 3.06 0.91 3.28 0.89 Sports MI 0.70 0.98 0.65 0.85 0.92 0.97 1.05 1.10 M2 1.87 1.29 1.50 1.03 1.26 0.89 1.46 1.05 M3 1.75 1.26 1.95 1.36 1.42 0.92 1.78 1.08 M4 1.81 1.50 1.92 1.01 1.49 1.04 2.05 1.36 TV viewing M1 2.21 1.29 2.05 1.22 2.10 1.23 2.10 1.21 M2 – – – – – – – – M3 1.99 1.27 1.95 1.09 2.18 1.23 2.04 1.12 M4 1.69 0.97 1.76 0.94 2.04 1.22 2.09 1.22 Child PA = child physical activity compared to other children (1 = much less to 5 = much more); Sports = total number of sports child participated in over the last year; TV viewing = child's frequency of viewing TV while getting ready for school (1 = never to 5 = always). All analyses were adjusted for parent gender, language of survey, survey version, parent age, marital status, household size, employment status, education status, homeownership status, parent income, child gender, child age, and child generation status; Family-only = Family intervention; Community-only = Community intervention; Family + Community = Family-plus-Community intervention Open in new tab Table 4 Descriptive statistics for child physical activity, sports participation, and TV viewing . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . Child PA M1 3.11 0.85 2.98 0.81 2.97 0.91 3.00 0.90 M2 3.47 0.72 3.28 0.80 3.18 0.86 3.05 0.85 M3 3.36 0.92 3.36 0.85 3.13 0.85 3.14 0.83 M4 3.41 0.84 3.15 0.80 3.06 0.91 3.28 0.89 Sports MI 0.70 0.98 0.65 0.85 0.92 0.97 1.05 1.10 M2 1.87 1.29 1.50 1.03 1.26 0.89 1.46 1.05 M3 1.75 1.26 1.95 1.36 1.42 0.92 1.78 1.08 M4 1.81 1.50 1.92 1.01 1.49 1.04 2.05 1.36 TV viewing M1 2.21 1.29 2.05 1.22 2.10 1.23 2.10 1.21 M2 – – – – – – – – M3 1.99 1.27 1.95 1.09 2.18 1.23 2.04 1.12 M4 1.69 0.97 1.76 0.94 2.04 1.22 2.09 1.22 . . Family + Community . Family-only . Community-only . Control . Outcome . Time . Mean . SD . Mean . SD . Mean . SD . Mean . SD . Child PA M1 3.11 0.85 2.98 0.81 2.97 0.91 3.00 0.90 M2 3.47 0.72 3.28 0.80 3.18 0.86 3.05 0.85 M3 3.36 0.92 3.36 0.85 3.13 0.85 3.14 0.83 M4 3.41 0.84 3.15 0.80 3.06 0.91 3.28 0.89 Sports MI 0.70 0.98 0.65 0.85 0.92 0.97 1.05 1.10 M2 1.87 1.29 1.50 1.03 1.26 0.89 1.46 1.05 M3 1.75 1.26 1.95 1.36 1.42 0.92 1.78 1.08 M4 1.81 1.50 1.92 1.01 1.49 1.04 2.05 1.36 TV viewing M1 2.21 1.29 2.05 1.22 2.10 1.23 2.10 1.21 M2 – – – – – – – – M3 1.99 1.27 1.95 1.09 2.18 1.23 2.04 1.12 M4 1.69 0.97 1.76 0.94 2.04 1.22 2.09 1.22 Child PA = child physical activity compared to other children (1 = much less to 5 = much more); Sports = total number of sports child participated in over the last year; TV viewing = child's frequency of viewing TV while getting ready for school (1 = never to 5 = always). All analyses were adjusted for parent gender, language of survey, survey version, parent age, marital status, household size, employment status, education status, homeownership status, parent income, child gender, child age, and child generation status; Family-only = Family intervention; Community-only = Community intervention; Family + Community = Family-plus-Community intervention Open in new tab Table 5 Model regression estimates and tests of hypotheses for primary and secondary outcomes . Outcomes . Model effects . BMI z-score . BMI percentile . Weight status . F & V . Snacks . . . . B (SE) . p value . B (SE) . p value . B (SE) . p value . B (SE) . p value . B (SE) . p value . . . Time × Family × Community interaction 0.49 0.30 0.70 0.75 0.055 M2/M4 −0.028 (0.081) −0.36 (2.34) 0.44 (0.81) −0.008 (0.34) 0.11 (0.30) M3/M4 −0.048 (0.067) 2.18 (1.93) 0.70 (0.83) −0.22 (0.35) 0.72 (0.32) Time × Community interaction 0.92 0.94 0.40 0.74 <0.01 M2/M4 −0.003 (0.040) 0.20 (1.16) 0.18 (0.40) 0.10 (0.17) −0.38 (0.17) M3/M4 −0.012 (0.033) 0.35 (0.96) −0.35 (0.41) 0.13 (0.17) 0.56 (0.16) Time by family interaction 0.26 0.15 0.78 0.35 0.10 M2/M4 −0.059 (0.040) −2.27 (1.16) 0.087 (0.41) 0.24 (0.17) −0.32 (0.16) M3/M4 −0.009 (0.034) −0.98 (0.96) 0.28 (0.41) 0.14 (0.17) −0.26 (0.16) Community by family interaction 0.016 (0.071) 0.83 0.25 (1.69) 0.88 −0.033 (0.63) 0.96 0.14 (0.23) 0.55 0.38 (0.43) 0.38 Community main effect −0.019 (0.033) 0.54 0.20 (0.84) 0.72 −0.19 (0.29) 0.53 −0.067 (0.10) 0.52 −0.082 (0.21) 0.70 Family main effect 0.003 (0.033) 0.92 0.72 (0.85) 0.40 0.036 (0.29) 0.90 0.27 (0.11) 0.011 0.42 (0.22) 0.056 SSBs Water Behavioral strategies: fat Child PA Sports TV viewing B (SE) p value B (SE) p value B (SE) p value B (SE) p value B (SE) p value B (SE) p value Time × Family × Community interaction 0.027 0.026 0.003 0.21 0.76 0.58 M2/M4 0.99 (0.50) 0.32 (0.41) 0.19 (0.11) −0.28 (0.20) 0.25 (0.34) M3/M4 1.34 (0.50) 1.16 (0.45) 0.39 (0.12) −0.35 (0.20) 0.081 (09.35) 0.14 (0.26) Time × Community interaction 0.57 0.27 0.12 0.46 0.17 0.14 M2/M4 −0.17 (0.23) −0.30 (0.20) −0.077 (0.053) 0.12 (0.097) 0.28 (0.17) M3/M4 0.02 (0.23) −0.067 (0.22) −0.12 (0.058) 0.059 (0.10) 0.013 (0.17) 0.19 (0.13) Time by Family interaction 0.96 0.10 0.76 0.26 0.77 0.49 M2/M4 0.066 (0.23) 0.43 (0.21) 0.019 (0.054) 0.12 (0.099) 0.12 (0.17) M3/M4 0.062 (0.24) 0.14 (0.22) −0.018 (0.058) 0.16 (0.10) 0.055 (0.17) 0.087 (0.13) Community by Family interaction −0.32 (0.33) 0.34 0.22 (0.25) 0.41 −0.009 (0.071) 0.90 0.054 (0.16) 0.74 0.32 (0.15) 0.035 −0.018 (0.19) 0.92 Community main effect −0.13 (0.16) 0.40 0.025 (0.12) 0.84 0.016 (0.033) 0.62 0.09 (0.077) 0.24 0.12 (0.11) 0.60 −0.095 (0.091) 0.29 Family main effect −0.17 (0.16) 0.29 0.044 (0.12) 0.72 0.13 (0.033) <0.0001 0.21 (0.078) 0.008 0.29 (0.11) 0.11 −0.20 (0.093) 0.033 . Outcomes . Model effects . BMI z-score . BMI percentile . Weight status . F & V . Snacks . . . . B (SE) . p value . B (SE) . p value . B (SE) . p value . B (SE) . p value . B (SE) . p value . . . Time × Family × Community interaction 0.49 0.30 0.70 0.75 0.055 M2/M4 −0.028 (0.081) −0.36 (2.34) 0.44 (0.81) −0.008 (0.34) 0.11 (0.30) M3/M4 −0.048 (0.067) 2.18 (1.93) 0.70 (0.83) −0.22 (0.35) 0.72 (0.32) Time × Community interaction 0.92 0.94 0.40 0.74 <0.01 M2/M4 −0.003 (0.040) 0.20 (1.16) 0.18 (0.40) 0.10 (0.17) −0.38 (0.17) M3/M4 −0.012 (0.033) 0.35 (0.96) −0.35 (0.41) 0.13 (0.17) 0.56 (0.16) Time by family interaction 0.26 0.15 0.78 0.35 0.10 M2/M4 −0.059 (0.040) −2.27 (1.16) 0.087 (0.41) 0.24 (0.17) −0.32 (0.16) M3/M4 −0.009 (0.034) −0.98 (0.96) 0.28 (0.41) 0.14 (0.17) −0.26 (0.16) Community by family interaction 0.016 (0.071) 0.83 0.25 (1.69) 0.88 −0.033 (0.63) 0.96 0.14 (0.23) 0.55 0.38 (0.43) 0.38 Community main effect −0.019 (0.033) 0.54 0.20 (0.84) 0.72 −0.19 (0.29) 0.53 −0.067 (0.10) 0.52 −0.082 (0.21) 0.70 Family main effect 0.003 (0.033) 0.92 0.72 (0.85) 0.40 0.036 (0.29) 0.90 0.27 (0.11) 0.011 0.42 (0.22) 0.056 SSBs Water Behavioral strategies: fat Child PA Sports TV viewing B (SE) p value B (SE) p value B (SE) p value B (SE) p value B (SE) p value B (SE) p value Time × Family × Community interaction 0.027 0.026 0.003 0.21 0.76 0.58 M2/M4 0.99 (0.50) 0.32 (0.41) 0.19 (0.11) −0.28 (0.20) 0.25 (0.34) M3/M4 1.34 (0.50) 1.16 (0.45) 0.39 (0.12) −0.35 (0.20) 0.081 (09.35) 0.14 (0.26) Time × Community interaction 0.57 0.27 0.12 0.46 0.17 0.14 M2/M4 −0.17 (0.23) −0.30 (0.20) −0.077 (0.053) 0.12 (0.097) 0.28 (0.17) M3/M4 0.02 (0.23) −0.067 (0.22) −0.12 (0.058) 0.059 (0.10) 0.013 (0.17) 0.19 (0.13) Time by Family interaction 0.96 0.10 0.76 0.26 0.77 0.49 M2/M4 0.066 (0.23) 0.43 (0.21) 0.019 (0.054) 0.12 (0.099) 0.12 (0.17) M3/M4 0.062 (0.24) 0.14 (0.22) −0.018 (0.058) 0.16 (0.10) 0.055 (0.17) 0.087 (0.13) Community by Family interaction −0.32 (0.33) 0.34 0.22 (0.25) 0.41 −0.009 (0.071) 0.90 0.054 (0.16) 0.74 0.32 (0.15) 0.035 −0.018 (0.19) 0.92 Community main effect −0.13 (0.16) 0.40 0.025 (0.12) 0.84 0.016 (0.033) 0.62 0.09 (0.077) 0.24 0.12 (0.11) 0.60 −0.095 (0.091) 0.29 Family main effect −0.17 (0.16) 0.29 0.044 (0.12) 0.72 0.13 (0.033) <0.0001 0.21 (0.078) 0.008 0.29 (0.11) 0.11 −0.20 (0.093) 0.033 Family = Family intervention; Community = Community intervention; Family + Community = Family-plus-Community intervention, BMI percentile = Body Mass Index percentile; F & V = Fruits and vegetables, SSBs = Sugary sweetened beverages; PA = Physical Activity Open in new tab Table 5 Model regression estimates and tests of hypotheses for primary and secondary outcomes . Outcomes . Model effects . BMI z-score . BMI percentile . Weight status . F & V . Snacks . . . . B (SE) . p value . B (SE) . p value . B (SE) . p value . B (SE) . p value . B (SE) . p value . . . Time × Family × Community interaction 0.49 0.30 0.70 0.75 0.055 M2/M4 −0.028 (0.081) −0.36 (2.34) 0.44 (0.81) −0.008 (0.34) 0.11 (0.30) M3/M4 −0.048 (0.067) 2.18 (1.93) 0.70 (0.83) −0.22 (0.35) 0.72 (0.32) Time × Community interaction 0.92 0.94 0.40 0.74 <0.01 M2/M4 −0.003 (0.040) 0.20 (1.16) 0.18 (0.40) 0.10 (0.17) −0.38 (0.17) M3/M4 −0.012 (0.033) 0.35 (0.96) −0.35 (0.41) 0.13 (0.17) 0.56 (0.16) Time by family interaction 0.26 0.15 0.78 0.35 0.10 M2/M4 −0.059 (0.040) −2.27 (1.16) 0.087 (0.41) 0.24 (0.17) −0.32 (0.16) M3/M4 −0.009 (0.034) −0.98 (0.96) 0.28 (0.41) 0.14 (0.17) −0.26 (0.16) Community by family interaction 0.016 (0.071) 0.83 0.25 (1.69) 0.88 −0.033 (0.63) 0.96 0.14 (0.23) 0.55 0.38 (0.43) 0.38 Community main effect −0.019 (0.033) 0.54 0.20 (0.84) 0.72 −0.19 (0.29) 0.53 −0.067 (0.10) 0.52 −0.082 (0.21) 0.70 Family main effect 0.003 (0.033) 0.92 0.72 (0.85) 0.40 0.036 (0.29) 0.90 0.27 (0.11) 0.011 0.42 (0.22) 0.056 SSBs Water Behavioral strategies: fat Child PA Sports TV viewing B (SE) p value B (SE) p value B (SE) p value B (SE) p value B (SE) p value B (SE) p value Time × Family × Community interaction 0.027 0.026 0.003 0.21 0.76 0.58 M2/M4 0.99 (0.50) 0.32 (0.41) 0.19 (0.11) −0.28 (0.20) 0.25 (0.34) M3/M4 1.34 (0.50) 1.16 (0.45) 0.39 (0.12) −0.35 (0.20) 0.081 (09.35) 0.14 (0.26) Time × Community interaction 0.57 0.27 0.12 0.46 0.17 0.14 M2/M4 −0.17 (0.23) −0.30 (0.20) −0.077 (0.053) 0.12 (0.097) 0.28 (0.17) M3/M4 0.02 (0.23) −0.067 (0.22) −0.12 (0.058) 0.059 (0.10) 0.013 (0.17) 0.19 (0.13) Time by Family interaction 0.96 0.10 0.76 0.26 0.77 0.49 M2/M4 0.066 (0.23) 0.43 (0.21) 0.019 (0.054) 0.12 (0.099) 0.12 (0.17) M3/M4 0.062 (0.24) 0.14 (0.22) −0.018 (0.058) 0.16 (0.10) 0.055 (0.17) 0.087 (0.13) Community by Family interaction −0.32 (0.33) 0.34 0.22 (0.25) 0.41 −0.009 (0.071) 0.90 0.054 (0.16) 0.74 0.32 (0.15) 0.035 −0.018 (0.19) 0.92 Community main effect −0.13 (0.16) 0.40 0.025 (0.12) 0.84 0.016 (0.033) 0.62 0.09 (0.077) 0.24 0.12 (0.11) 0.60 −0.095 (0.091) 0.29 Family main effect −0.17 (0.16) 0.29 0.044 (0.12) 0.72 0.13 (0.033) <0.0001 0.21 (0.078) 0.008 0.29 (0.11) 0.11 −0.20 (0.093) 0.033 . Outcomes . Model effects . BMI z-score . BMI percentile . Weight status . F & V . Snacks . . . . B (SE) . p value . B (SE) . p value . B (SE) . p value . B (SE) . p value . B (SE) . p value . . . Time × Family × Community interaction 0.49 0.30 0.70 0.75 0.055 M2/M4 −0.028 (0.081) −0.36 (2.34) 0.44 (0.81) −0.008 (0.34) 0.11 (0.30) M3/M4 −0.048 (0.067) 2.18 (1.93) 0.70 (0.83) −0.22 (0.35) 0.72 (0.32) Time × Community interaction 0.92 0.94 0.40 0.74 <0.01 M2/M4 −0.003 (0.040) 0.20 (1.16) 0.18 (0.40) 0.10 (0.17) −0.38 (0.17) M3/M4 −0.012 (0.033) 0.35 (0.96) −0.35 (0.41) 0.13 (0.17) 0.56 (0.16) Time by family interaction 0.26 0.15 0.78 0.35 0.10 M2/M4 −0.059 (0.040) −2.27 (1.16) 0.087 (0.41) 0.24 (0.17) −0.32 (0.16) M3/M4 −0.009 (0.034) −0.98 (0.96) 0.28 (0.41) 0.14 (0.17) −0.26 (0.16) Community by family interaction 0.016 (0.071) 0.83 0.25 (1.69) 0.88 −0.033 (0.63) 0.96 0.14 (0.23) 0.55 0.38 (0.43) 0.38 Community main effect −0.019 (0.033) 0.54 0.20 (0.84) 0.72 −0.19 (0.29) 0.53 −0.067 (0.10) 0.52 −0.082 (0.21) 0.70 Family main effect 0.003 (0.033) 0.92 0.72 (0.85) 0.40 0.036 (0.29) 0.90 0.27 (0.11) 0.011 0.42 (0.22) 0.056 SSBs Water Behavioral strategies: fat Child PA Sports TV viewing B (SE) p value B (SE) p value B (SE) p value B (SE) p value B (SE) p value B (SE) p value Time × Family × Community interaction 0.027 0.026 0.003 0.21 0.76 0.58 M2/M4 0.99 (0.50) 0.32 (0.41) 0.19 (0.11) −0.28 (0.20) 0.25 (0.34) M3/M4 1.34 (0.50) 1.16 (0.45) 0.39 (0.12) −0.35 (0.20) 0.081 (09.35) 0.14 (0.26) Time × Community interaction 0.57 0.27 0.12 0.46 0.17 0.14 M2/M4 −0.17 (0.23) −0.30 (0.20) −0.077 (0.053) 0.12 (0.097) 0.28 (0.17) M3/M4 0.02 (0.23) −0.067 (0.22) −0.12 (0.058) 0.059 (0.10) 0.013 (0.17) 0.19 (0.13) Time by Family interaction 0.96 0.10 0.76 0.26 0.77 0.49 M2/M4 0.066 (0.23) 0.43 (0.21) 0.019 (0.054) 0.12 (0.099) 0.12 (0.17) M3/M4 0.062 (0.24) 0.14 (0.22) −0.018 (0.058) 0.16 (0.10) 0.055 (0.17) 0.087 (0.13) Community by Family interaction −0.32 (0.33) 0.34 0.22 (0.25) 0.41 −0.009 (0.071) 0.90 0.054 (0.16) 0.74 0.32 (0.15) 0.035 −0.018 (0.19) 0.92 Community main effect −0.13 (0.16) 0.40 0.025 (0.12) 0.84 0.016 (0.033) 0.62 0.09 (0.077) 0.24 0.12 (0.11) 0.60 −0.095 (0.091) 0.29 Family main effect −0.17 (0.16) 0.29 0.044 (0.12) 0.72 0.13 (0.033) <0.0001 0.21 (0.078) 0.008 0.29 (0.11) 0.11 −0.20 (0.093) 0.033 Family = Family intervention; Community = Community intervention; Family + Community = Family-plus-Community intervention, BMI percentile = Body Mass Index percentile; F & V = Fruits and vegetables, SSBs = Sugary sweetened beverages; PA = Physical Activity Open in new tab Mediation Effects of Secondary Outcomes Table 6 displays the significant family intervention-related parental and family mediators of child secondary outcomes. These parental mediated factors were selected based on the results of previous analyses of intervention effects on parental factors [60]. The ‘ab’ column estimates the mediation effect and the far right column in the table indicates the estimated percentage of the total intervention effect that is mediated by that variable. Results showed that four child behavioral outcomes were significantly mediated by parental factors as a result of the family intervention. Increases in parent-reported child physical activity were mediated by increases in parental monitoring of children's eating and activity and parent support for child physical activity. Reductions in child viewing of TV while getting ready for school were mediated by increases in parental monitoring of children's eating and activity. Increases in parent use of behavioral strategies to reduce fat were mediated by increases in parent monitoring and reinforcement for children's eating and physical activity as well as reductions in family viewing of TV during dinner. Increases in child consumption of fruits and vegetables were mediated by increases in parent monitoring and reinforcement and reduction of control of children's eating and physical activity, as well as reductions in family viewing of TV during dinner. Family watching TV during dinner and away from home eating were not included in mediation analyses since they were not affected by the intervention. Table 6 Results of family intervention mediation analyses for select parental and family factors on select secondary child behavioral outcomes . . . . 95% CI for ab . . Outcome with Mediators . a . b . ab . LL . UL . % med . Child PA Parent monitoring of diet & PA .1353 .1036 .01402* .0026 .0296 7.0 Parent control of diet & PA −.3069 −.0013 .00039 −.0136 .0145 1.9 Parent reinforcement diet & PA .2116 .0752 .01591* .0043 .0317 7.7 Parental support for PA .3694 .1163 .04296* .0229 .0665 21.7 Sports Parent monitoring of diet & PA .1353 −.0266 −.00360 −.0178 .0084 1.1 Parent control of diet & PA −.3069 −.0462 .01418 −.0074 .0400 4.2 Parent reinforcement diet & PA .2116 .0335 .00709 −.0077 .0250 2.2 Parental support for PA .3694 .0437 .01614 −.0037 .0395 5.1 TV viewing Parent monitoring of diet & PA .1353 −.1943 −.0263* −.0541 −.0051 13.7 Parent control of diet & PA −.3069 −.0482 .01480 −.0078 .0419 6.6 Parent reinforcement diet & PA .2116 −.0484 −.01024 −.0302 .0052 5.5 Behavioral Strategies: Fat Parent monitoring of diet & PA .1353 .0895 .01212* .0025 .0238 9.2 Parent control of diet & PA −.3069 −.0243 .00745 −.0002 .0172 5.6 Parent reinforcement diet & PA .2116 .0599 .01269* .0041 .0236 9.3 Away from home foods −.1679 −.0095 .00160 −.0022 .0066 1.2 Family watches TV during dinner −.1871 −.0291 .00544* .0008 .0122 4.1 F&V Parent monitoring of diet & PA .1353 .1779 .02407* .0044 .0510 9.0 Parent control of diet & PA −.3069 .0880 −.02701* −.0575 −.0037 8.2 Parent reinforcement diet & PA .2116 .0976 .02065* .0032 .0453 7.5 Away from home foods −.1679 −.0247 .00415 −.0074 .0189 1.5 Family watches TV during dinner −.1871 −.0813 .01520* .0017 .0349 5.6 . . . . 95% CI for ab . . Outcome with Mediators . a . b . ab . LL . UL . % med . Child PA Parent monitoring of diet & PA .1353 .1036 .01402* .0026 .0296 7.0 Parent control of diet & PA −.3069 −.0013 .00039 −.0136 .0145 1.9 Parent reinforcement diet & PA .2116 .0752 .01591* .0043 .0317 7.7 Parental support for PA .3694 .1163 .04296* .0229 .0665 21.7 Sports Parent monitoring of diet & PA .1353 −.0266 −.00360 −.0178 .0084 1.1 Parent control of diet & PA −.3069 −.0462 .01418 −.0074 .0400 4.2 Parent reinforcement diet & PA .2116 .0335 .00709 −.0077 .0250 2.2 Parental support for PA .3694 .0437 .01614 −.0037 .0395 5.1 TV viewing Parent monitoring of diet & PA .1353 −.1943 −.0263* −.0541 −.0051 13.7 Parent control of diet & PA −.3069 −.0482 .01480 −.0078 .0419 6.6 Parent reinforcement diet & PA .2116 −.0484 −.01024 −.0302 .0052 5.5 Behavioral Strategies: Fat Parent monitoring of diet & PA .1353 .0895 .01212* .0025 .0238 9.2 Parent control of diet & PA −.3069 −.0243 .00745 −.0002 .0172 5.6 Parent reinforcement diet & PA .2116 .0599 .01269* .0041 .0236 9.3 Away from home foods −.1679 −.0095 .00160 −.0022 .0066 1.2 Family watches TV during dinner −.1871 −.0291 .00544* .0008 .0122 4.1 F&V Parent monitoring of diet & PA .1353 .1779 .02407* .0044 .0510 9.0 Parent control of diet & PA −.3069 .0880 −.02701* −.0575 −.0037 8.2 Parent reinforcement diet & PA .2116 .0976 .02065* .0032 .0453 7.5 Away from home foods −.1679 −.0247 .00415 −.0074 .0189 1.5 Family watches TV during dinner −.1871 −.0813 .01520* .0017 .0349 5.6 a = Family intervention effect on mediator; b = mediator effect on outcome adjusting for intervention; ab = mediated effect; CI = confidence interval; LL = lower limit; UL = upper limit; % med = proportion of the absolute total effect that is mediated; Child PA = child physical activity compared to other children (1=much less to 5=much more); Sports = total number of sports child participated in over the last year; TV viewing = child's frequency of viewing TV when getting ready for school (1=never to 5=always); Behavioral Strategies: Fat = total number of behavioral strategies parent uses to reduce fat in family's diet; and F&V = total number of fruits and vegetables child consumes per day in a typical week. * p < .05 Open in new tab Table 6 Results of family intervention mediation analyses for select parental and family factors on select secondary child behavioral outcomes . . . . 95% CI for ab . . Outcome with Mediators . a . b . ab . LL . UL . % med . Child PA Parent monitoring of diet & PA .1353 .1036 .01402* .0026 .0296 7.0 Parent control of diet & PA −.3069 −.0013 .00039 −.0136 .0145 1.9 Parent reinforcement diet & PA .2116 .0752 .01591* .0043 .0317 7.7 Parental support for PA .3694 .1163 .04296* .0229 .0665 21.7 Sports Parent monitoring of diet & PA .1353 −.0266 −.00360 −.0178 .0084 1.1 Parent control of diet & PA −.3069 −.0462 .01418 −.0074 .0400 4.2 Parent reinforcement diet & PA .2116 .0335 .00709 −.0077 .0250 2.2 Parental support for PA .3694 .0437 .01614 −.0037 .0395 5.1 TV viewing Parent monitoring of diet & PA .1353 −.1943 −.0263* −.0541 −.0051 13.7 Parent control of diet & PA −.3069 −.0482 .01480 −.0078 .0419 6.6 Parent reinforcement diet & PA .2116 −.0484 −.01024 −.0302 .0052 5.5 Behavioral Strategies: Fat Parent monitoring of diet & PA .1353 .0895 .01212* .0025 .0238 9.2 Parent control of diet & PA −.3069 −.0243 .00745 −.0002 .0172 5.6 Parent reinforcement diet & PA .2116 .0599 .01269* .0041 .0236 9.3 Away from home foods −.1679 −.0095 .00160 −.0022 .0066 1.2 Family watches TV during dinner −.1871 −.0291 .00544* .0008 .0122 4.1 F&V Parent monitoring of diet & PA .1353 .1779 .02407* .0044 .0510 9.0 Parent control of diet & PA −.3069 .0880 −.02701* −.0575 −.0037 8.2 Parent reinforcement diet & PA .2116 .0976 .02065* .0032 .0453 7.5 Away from home foods −.1679 −.0247 .00415 −.0074 .0189 1.5 Family watches TV during dinner −.1871 −.0813 .01520* .0017 .0349 5.6 . . . . 95% CI for ab . . Outcome with Mediators . a . b . ab . LL . UL . % med . Child PA Parent monitoring of diet & PA .1353 .1036 .01402* .0026 .0296 7.0 Parent control of diet & PA −.3069 −.0013 .00039 −.0136 .0145 1.9 Parent reinforcement diet & PA .2116 .0752 .01591* .0043 .0317 7.7 Parental support for PA .3694 .1163 .04296* .0229 .0665 21.7 Sports Parent monitoring of diet & PA .1353 −.0266 −.00360 −.0178 .0084 1.1 Parent control of diet & PA −.3069 −.0462 .01418 −.0074 .0400 4.2 Parent reinforcement diet & PA .2116 .0335 .00709 −.0077 .0250 2.2 Parental support for PA .3694 .0437 .01614 −.0037 .0395 5.1 TV viewing Parent monitoring of diet & PA .1353 −.1943 −.0263* −.0541 −.0051 13.7 Parent control of diet & PA −.3069 −.0482 .01480 −.0078 .0419 6.6 Parent reinforcement diet & PA .2116 −.0484 −.01024 −.0302 .0052 5.5 Behavioral Strategies: Fat Parent monitoring of diet & PA .1353 .0895 .01212* .0025 .0238 9.2 Parent control of diet & PA −.3069 −.0243 .00745 −.0002 .0172 5.6 Parent reinforcement diet & PA .2116 .0599 .01269* .0041 .0236 9.3 Away from home foods −.1679 −.0095 .00160 −.0022 .0066 1.2 Family watches TV during dinner −.1871 −.0291 .00544* .0008 .0122 4.1 F&V Parent monitoring of diet & PA .1353 .1779 .02407* .0044 .0510 9.0 Parent control of diet & PA −.3069 .0880 −.02701* −.0575 −.0037 8.2 Parent reinforcement diet & PA .2116 .0976 .02065* .0032 .0453 7.5 Away from home foods −.1679 −.0247 .00415 −.0074 .0189 1.5 Family watches TV during dinner −.1871 −.0813 .01520* .0017 .0349 5.6 a = Family intervention effect on mediator; b = mediator effect on outcome adjusting for intervention; ab = mediated effect; CI = confidence interval; LL = lower limit; UL = upper limit; % med = proportion of the absolute total effect that is mediated; Child PA = child physical activity compared to other children (1=much less to 5=much more); Sports = total number of sports child participated in over the last year; TV viewing = child's frequency of viewing TV when getting ready for school (1=never to 5=always); Behavioral Strategies: Fat = total number of behavioral strategies parent uses to reduce fat in family's diet; and F&V = total number of fruits and vegetables child consumes per day in a typical week. * p < .05 Open in new tab Environmental Changes Restaurants Initial contacts with 153 restaurants began in the fall of the second intervention year. Of these, 41 (28%) were chains. This resulted in a final list of 112 non-chain restaurants approached to participate in the intervention and 61 (54%) agreeing to participate. At 16 months, 36 restaurants were still using Aventuras menus. Parks The 300 signature-petition for park improvements was presented to the San Diego City Council and received unanimous support from a then-newly elected council member who eventually got the Council to award $436,000 to renovate one of the larger parks. Discussion The present study examined the direct and indirect effects of modifying home (parenting) and community (school, park, and food retail) environments for the primary prevention of childhood obesity in young Latino elementary school-aged children. This is one of few initiatives to emphasize the impact of changes across levels of the socioecological model [5] on child BMI z-score. More specifically, it was hypothesized that the combined family and community intervention would have a stronger impact on children's BMI z-score compared to the family or community level intervention alone. Our findings suggest no significant main effects or interactions for the family or community intervention, which is consistent with results from a systematic review [34]. It is possible that there were truly no aggregate effects of the family and community intervention on children's BMI z-score compared to either condition alone. Also, variability in the adherence of intervention activities may have diluted the effects of the intervention (Table 1). Other possible explanations for the null findings related to child BMI z-score may be due to the need for more intensive or more targeted interventions. There are a wide variety of possible explanations for the null results in terms of child BMI z-score. It is conceivable that the significant changes in parental and child behaviors were to a degree products of self-report measurement bias, while the outcome for the present study was measured through physical assessments of child height and weight. Alternatively, changes in parenting and concomitant changes in the child's food and physical activity environments may have been insufficient to have an impact on the child's weight status, in turn, a product of genetic, biological, and other factors not targeted in the study [63]. This interpretation is also supported by a recent school-based study, which showed significant reductions in BMI using strategies to change policy, school environment, and parental influences [64], perhaps insufficiently changed in the present study. Another reason that may have limited this study's ability to detect significant intervention effects on child BMI z-score may have been the relatively high attrition rates observed (a common problem in large community trials with mobile populations), ranging from 41% to 52% among the four groups, thus impacting the power to detect effects. Most cases of ‘lost to follow-up’ or ‘missing measurement time points’ were due to participants moving from their residence, which made it challenging to track and maintain communication with these participants. Of importance is the fact that retention rates did not appear to differ substantially between the four groups. The family main effects showed that children who received the family intervention were perceived to be more physically active by their caregiver, viewed TV less frequently, and increased daily consumption of fruits and vegetables than children who did not receive the family intervention. Our findings support our second hypothesis regarding the stronger effects for the Family + Community intervention. However, this effect was not achieved for all secondary outcomes and not consistent in all time points. For example, at M2, children in the Family + Community group had a lower mean consumption of sugary-sweetened beverages than the other groups, but this pattern diminished at M3 and M4 (Table 3). This result is consistent with intervention targets (e.g., reduce consumption of sugary-sweetened beverages); however, it is not clear why the effects were not consistent over time. It is conceivable that families did achieve behavioral changes during the intervention (e.g., at M2) but then focused on other behaviors or possibly reached a plateau for that behavior. This may explain the inconsistency of results over time. Some success was indicated for the program as evidenced by the results of mediational analyses (supporting our third hypothesis). The family intervention, creating more changes in the child's ‘proximal’ environment [5], appeared to have changed specific parenting practices that resulted in favorable child behavioral outcomes (Table 6). For example, increased parent monitoring for child diet and physical activity was related to subsequent increases in parent-reported child physical activity, increased use of parent behavioral strategies to reduce fat, increases in child consumption of fruits and vegetables, and a reduction in child viewing TV when getting ready for school. These results support the role of parents to influence children's obesity-related health behaviors. Aventuras supports previous studies showing associations between parental factors and child behaviors, and suggests that the family intervention was a viable method for changing child physical activity, sedentary, and dietary behaviors. Important environmental improvements were achieved; thus, many aspects of this innovative approach proved feasible. School cafeteria staff made substantial changes in the way they promoted the selection of healthy foods through the Aventuras ‘Start with Salad’ program. Recesses, physical education classes, and even playgrounds themselves were restructured in ways that promoted more active leisure time among the students in the school. Restaurants and grocery stores as well as the parents became active partners in the promotion of lower calorie and more nutritious food consumption for the children in the targeted neighborhoods. Most importantly, community planners and elected officials were able to understand the decrepit condition of city parks in the targeted neighborhoods and decided to take action to remediate these problems. Thus, relatively permanent or at least medium-term changes were realized in these environments (and not in control neighborhoods). The potential importance of these changes in the ‘distal’ environment should not be underestimated even if they did not produce immediate individual weight changes. Similarly, although some of the restaurants were unable to maintain the study menu following study completion due to challenges in implementation (e.g., ongoing training of restaurant staff to make menu changes and suggest menu items to customers), the fact that over 50% did maintain these menus requires further exploration. Perhaps one approach to improve program implementation is to engage school personnel and restaurant owners in developing strategies to help make changes in schools, restaurants, and other food venues. This approach would be more consistent with a community-based participatory research approach [65], which may improve program adherence. Study limitations include parent self-report survey measures, which are subject to self-report bias. We did not include a measure of social desirability in the survey, which could have been used to adjust for such bias in the analyses. Finally, some measures such as child physical activity consisted of a single parent self-report item. Such measures are less valid than more objective measures (e.g., accelerometry). Thereby, conclusions about the impact of the intervention on these single-item measures are limited. More research is needed to understand the relative and combined contributions of multilevel factors on childhood obesity as well as the feasibility of changing these factors. Baranowski et al. [66] have labeled these childhood obesity research priorities as “behavioral,” “mediator,” and “intervention procedure validation.” Based on our study, it would appear that family intervention strategies should target changes in parenting styles and in other ways restructure the home environment to support physical activity and healthy eating behaviors. Additional research is needed to determine the most effective policy and environmental changes to promote greater physical activity and healthy eating, and whether these two targets can be addressed concurrently [34] and whether intervention strategies are equally effective based on demographic factors such as child's gender. Methodological considerations should include tailoring health messages and intervention strategies based on baseline child weight categories, the frequency of measuring child BMI z-score or the use of multiple body fat measures to improve sensitivity to change, and a determination of how extensive environmental changes must be to favorably alter childhood overweight and obesity rates. The present study highlights the need to collect more detailed process data in order to more accurately decipher which aspects of the intervention may have been more or less effective. 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TI - Results of a Multi-level Intervention to Prevent and Control Childhood Obesity among Latino Children: The Aventuras Para Niños Study
JF - Annals of Behavioral Medicine
DO - 10.1007/s12160-011-9332-7
DA - 2012-02-01
UR - https://www.deepdyve.com/lp/oxford-university-press/results-of-a-multi-level-intervention-to-prevent-and-control-childhood-ZKAmHhbeQL
SP - 84
EP - 100
VL - 43
IS - 1
DP - DeepDyve
ER -